21 April 2008

Hospitals are unusual places. They are public facilities, open access, with folks coming and going at all hours. It's easy enough to blend in with the crowd. Our institution is big enough to justify having our own security corps -- quite a sizable one, in fact. They spend a lot of time in the ER, with our various intoxicated or disturbed patients, as well as just patrolling the grounds in general.

Sometimes they make an unexpected discovery. The other day they learned that the armoire in the surgical waiting lounge had been placed in front of a largish recess in the wall, and a local homeless guy had been living there. He had just wandered in one day, unchallenged, and with the resourcefulness of someone who has spent part of his life living on the street, he poked around and found this little hidey-hole, which he made his home.For three months.

Security happened to notice him sitting in the lounge late one night, watching TV, as if in his own living room, and he looked suspicious enough for them to question him. Once caught, the guy gave up the ghost and showed them his little nest, which was very well equipped with pillows, blankets, and all his personal gear. He had been showering in one of the bathrooms, and had stolen cafeteria food cached in various hiding places on several different inpatient units.

While it's easy enough to blame lax security for this sort of thing, I think it's unfair in this sort of setting. Rather, I prefer to admire the ingenuity and chutzpah of the homeless guy. Seriously, to go from living under a bridge to living in the hospital itself? It's the life of riley: safe, warm, comfortable, with food, bath, and TV -- it must have felt like the Four Seasons to him. And to pull it off for so long. Just awesome.

Security must have been impressed with the guy, as well. They evicted him, but instead of frog-marching him off hospital property and pressing trespass charges, they actually gave him a ride to the local mission and checked him in there.

Though maybe they just wanted to make double sure he didn't come right back to the hospital.

20 April 2008

18 April 2008

Federal health officials on Monday proposed adding dangerous blood clots in the leg and eight other conditions to the list of complications that Medicare won't pay to treat if they were acquired at the hospital.

Included in this are, among others, Iatrogenic Pneumothorax and DVTs.

I was going to bitch and moan that this is stupid. But I'm not going to.

Not that it isn't wrongheaded and misguided. There are a lot of things not to like in this proposal. As Roy points out, using delerium as an example, there is no reliable way to prevent some of these "never" events, and that despite best efforts there will remain an irreducible incidence of these conditions.

The persistence of complications shouldn't preclude a certain condition or procedure from being targeted as a core quality measure. As Atul Gawande pointed out, central line infections can be largely though not completely eliminated, and there is good organizational quality research to back that up, which makes it reasonable for that to be a metric that should be focused on. Conversely, most simple iatrogenic pneumothoraces are caused by central line placement, thoracentesis, or lung biopsies. Sticking needles into peoples' chests is, from time to time going to puncture a lung; it is an inherent risk of the procedure. There is, to my knowledge, no comparable study or program to reduce the incidence of pneumothoraces after central line insertion.

Further, it is nonsensical to make peumothorax a facility quality indicator. If there is some quality component to this complication, it is in the skill of the practitioner who performs the procedure, not the facility. While well-developed programs to reduce ventilator-acquired pneumonia can be implemented by the facility, it is unclear to me how facilities might impact the skill of doctors putting in central lines, or surgeons performing biopsies.

I was going to make these arguments and more, at length and with lavish attention to detail. But I'm not going to. What I would rather do is point out is the fundamental dishonesty which underlies this initiative.

CMS would have you believe that this is about quality and patient safety. Who can argue with those laudable goals? They are so revered as to be sacred, and with good reason. But don't be fooled. This is cost containment masquerading as quality. As we start to see more and more of these unpreventable "never" events proliferating, and more and more payors signing on to the concept of not paying for "errors" you will see that this is really about reducing the total amount that the big payors spend on the care of sick patients, and shifting the risk of caring for the critically ill onto care providers. It is also informative that CMS is focusing on payments to hospitals, which are much more expensive than the payments to physicians, despite the fact that physicians would theoretically be just as sensitive to payment reductions and are in a position to more directly improve the "quality" of care.

As quality -- a critical and praise-worthy mission -- becomes hijacked by financial considerations, we are seeing how quickly the dollars drive the real and sensible quality indicators off the rails. This is a compelling argument for keeping the two separate. If CMS needs to cut costs, then they should do so in a clear and transparent manner. Policies that are designed to improve care will be met with skepticism and resistance from physicians and hospitals, suspicious of the ulterior motivation of the payors, so long as these policies continue to link dollars to the complications. Quality metrics which are designed with an eye to saving money are more likely to save money than to save lives.

We haven't a hope in hades of stopping this runaway freight train, not with the current administration, and probably even less likely under its successor. It's too far down the tracks now, and too deeply embedded in the brainstems of the bureaucrats at CMS and TJC. At the least we should be sure to provide our feedback, and try to keep the quality metrics relevant and achievable. One link that should be prominently featured on every blog post that references this proposed rule is this:

http://www.regulations.gov

This is at this time just a proposed rule, and the period for public comments is open until (I think) June 13. Click on the link and follow the instructions for "Comment or Submission" and enter the file code CMS-1390-P to submit comments on this proposed rule.

Update:

This link should take you directly to the appropriate page to leave a comment.

17 April 2008

I recently cared for a young boy with abdominal pain. He was about six years old, and had pain in his lower abdomen for about 12 hours prior to coming to the ER. His parents, Ukranian immigrants, were really nice people. Their English could have been a little better, but we could understand one another perfectly with a little effort and we got along fine. They were among the nicest people I have had the pleasure of interacting with in the ER in a long time. They were reserved, polite, and deeply respectful towards me in a manner that struck me as almost old-fashioned, and they were very concerned about their son, their only child, who was in a lot of pain and had never been ill like this before.

I was almost certain that he had appendicitis, and after explaining this to the parents, I called the surgeon to see if we could just take him to the OR for a laparotomy. You may recall I've run into trouble with this sort of thing before, and the surgeon, the same surgeon as before, wouldn't bite this time. In fairness, the story wasn't quite perfect -- the pain didn't localize quite right, the white count wasn't really high enough, etc -- so she asked me to image the child to verify the diagnosis, which is reasonable.

In the interim, a large contingent of extended family had congregated in the ER; they were also polite and stayed out of our way. I explained that we would be doing an ultrasound on his abdomen to try to see if the appendix was inflamed. Unfortunately, it took a while to get the study, and is often the case, it was non-diagnostic. Often the appendix "hides" behind the cecum and the sono tech just can't visualize it.

So I went back into the room and told the family that we would need to do a CT scan. They had been in the ER for several hours now and were beginning to get a bit frustrated by the lack of any apparent progress; their son was still hurting and we hadn't "done" anything for him. (Though he had had fluids, pain medicine, and antibiotics.) Still unfailingly polite, but a bit frayed, they wanted to know why, if a CT scan was more precise, we hadn't just done it in the first place.

I explained that since he was young, there was a high value placed on avoiding radiation and a CT scan involves a fair amount of ionizing radiation; since a ultrasound does not have radiation, we do that study first, and only do a CT if it's necessary.

As I said this, they stiffened, and their whole demeanor changed, from incredulity, to fear and outright hostility. The mother immediately said that she was taking her boy home and began bundling him up -- only the presence of the IV catheter keep her from storming out; she couldn't quite figure out how to get it out. The father started yelling at me angrily, but I couldn't quite understand his gist. I was stunned. Nothing in our interaction had prepared me for a behavior shift like this, and I had no idea how to defuse it, or even where it had come from. We talked past each other for a minute or two until one of the teenaged relatives took me by the elbow and led me outside the room.

"You have to understand their feelings about radiation. It scares them a lot. They are from Kiev, in the Ukraine." He looked at me expectantly, but I didn't get it at first.

Oh.

"Chernobyl?" I ventured. He nodded.

No wonder they were freaked out by the mention of radiation.

We went back into the room. By that time some other family members had managed to calm the parents down. I tried to give them the logical take on radiation doses, risks versus benefits, and all that, but their rational brains had clearly shut down. Finally, lacking anything else, I pointed out that I had a five-year-old son, and if it were my son with the same pains, I would not hesitate to put my son in the scanner.

That did it. It was all they needed to hear and they trusted me again. If "the doctor" would do it for his own son, then it must be OK. All of a sudden they were happy and content again, signed the papers for the test, and off they went to the scanner, which confirmed the appendicitis.

Several days later, they tracked me down in the ER and brought me some savory pastry things to eat. I don't know what they were, but they were delicious.

13 April 2008

Had a lovely time visiting a former partner now living in San Diego. It's much warmer and sunnier there than in the Pacific NW. Who knew? Kids liked the beach and SeaWorld and all that stuff. Now I'm back at work, working the night shift.

Hypothetically, when I take care of a "Level 5" patient -- a complex patient requiring lots of diagnostic work and risk -- my gross charges might be $474.

However, most patients pay much less, because their insurers negotiate a lower payment rate. Medicare patients pay less than half, about $180, based on the medicare fee schedule. Private insurers -- Blue Cross, Aetna, UnitedHealth, etc, will individually negotiate rates with the physician group, typically getting a discount anywhere from 15-50%, depending on the size and political clout of the plan. They promise rapid payment with less hassle in return for this discount. However, the demands are typically for very deep discounts, and as the representative for our physician group my job is to try to keep payments as high as possible, largely to offset the losses we take on uninsured and medicaid patients.

The only leverage I have to extract concessions from insurers is to walk away from the table and go "non-participating" or "non-par" with a given insurer. In that case, the patient gets no discount and is responsible for the full charge. The insurer will usually send a token payment, and the patient is billed for the balance. This sucks for patients who thought they had purchased insurance to cover their medical expenses. Typically, in response to such a threat -- or a notice of termination letter -- the plans will respond with a reasonable compromise. The doctors' only alternative is to bend over and take whatever pittance the insurance companies offer.

If the balance billing prohibition is enacted, insurance companies will have the ability to drive down physician reimbursements with no recourse whatsoever. They can use the threat of paying non-par physicians at Medicaid rates to force doctors to contract at unsustainably deep discounts.

CA-ACEP and CMA are opposing this - good for them. But with the Governor in their pocket, the big bucks the insurers can apply to the legislators and the phony patient-advocate spin they're putting on it, I worry that the deck is stacked against them.

01 April 2008

According to a survey published in AIM, 59% of physicians favor legislation to establish national health insurance.

Predictably, Physicians for a National Health Care Program jumped right out there claiming that doctors support single payer, which I think is not at all supported by the study, which did not even try to define the type of national plan. Moreover, that 55% support "incremental" reform probably indicates underwhelming enthusiasm for single payer.

While there's some reliability in comparing this poll to a similar one in 2002 and concluding that support among docs for reform is building, I just can't accept it at face value. The responder bias alone probably undercuts the validity -- the docs most enthusiastic for reform are much more likely to take the time to fill out a survey.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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